Fillable Arizona Department of Agriculture Federal Organic Certification Cost (Arizona)

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Arizona Department of Agriculture Federal Organic Certification Cost (Arizona)

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Arizona Organic Program
Rev. 04/2015
Arizona Department of Agriculture
Federal Organic Certification Cost Share Application
To be eligible for reimbursement the operation must have received organic certification on or between October 1, 2018,
and September 30, 2019. The amount of reimbursement is 75% of certification costs (maximum of $750)
PRODUCER/HANDLER IDENTIFICATION
First Name and/or Company Name
M.I.
Last Name
Address
City
County
State
Zip Code
Phone Number
Fax Number
Email Address (Required)
Organic Certification Number
Social Security Number or Employer Identification Number (EIN)
CERTIFICATION INFORMATION
Name of Certification Agent
Issue Date of Certification
Application Fee Paid
Annual Fee Paid
Total Amount of Fees Paid for Certification:
Date Fees Billed
Date Fees Paid
NOTE: You must attach a copy of your certification, billing, and proof of payment to your application.
SIGNATURE
Certification by Producer:
I certify that the above information is true and correct, and the operation stated above received organic certification on or
between October 1, 2018, and September 30, 2019.
Notice of Penalties: Penalty for knowingly making false statements or false entries, or attempts to secure money
through fraudulent means, may include fines and/or incarceration and/or forfeiture of agriculture assistance funds
under applicable federal and state law.
Date
Certified Operations Signature
Month / Day / Year
Email OR Mail Application and Supporting
Documents To:
For Official Use Only
rnick@azda.gov
Application Number
Reimbursable Costs From Invoice
Arizona Department of Agriculture
Citrus, Fruit and Vegetable
□75% =
$
□ $750
Cost Share Reimbursement
Approved By
Date
1688 West Adams Street
Phoenix, Arizona 85007
Certificate Type: □ Crops □ Handling □ Other
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Arizona Department of Agriculture Federal Organic Certification Cost (Arizona)

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Completed 27 January 2021

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